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Group Health Insurance Policy

It is no secret that employees play an important role in the formation of an organisation and are regarded as a valuable asset. Thus, it is important to ensure they are healthy and free from diseases. This is where the importance of a group health insurance policy comes in! Group Health Insurance, also known as Corporate Health Insurance, provides coverage to employees within an organisation. This kind of insurance policy provides a wide array of medical benefits to insured individuals and their families which ensure access to essential healthcare services. From routine doctor visits to hospital stays and prescription medicines to specialised treatments, the group health insurance plan offers protection against unexpected medical expenses.

Corporate health insurance policy generally covers pre-hospitalisation, post-hospitalisation expenses, and pre-existing conditions. Moreover, these group health insurance plans enable employers to select the ideal coverage level that aligns with the specific needs of their employees.

Read on to learn more about the group health insurance policy’s key features & benefits, inclusions, exclusions, buying process, claim procedure, factors to consider, and more.

What Are the Features & Benefits of Group Health Insurance Policy?

Here is the list of the features and benefits of the Group health insurance policy.

  • Comprehensive Coverage

One of the key features and benefits of considering the group health insurance policy is that it offers comprehensive coverage to employees without the need for pre-medical examinations. This coverage can include maternity benefits, regular doctor consultations, and many other inclusions, depending on the specific terms of the policy. Unlike individual insurance plans, which often require policyholders to undergo medical tests before purchasing coverage, group health insurance generally does not mandate any pre-purchase medical tests for employees.

  • Improve Employee Retention

Another major feature and benefit of choosing corporate health insurance is that it offers health coverage for your employees and their dependents to provide them with a layer of financial security during medical emergencies. It not only showcases care for their well-being but offers a sense of loyalty and commitment among employees towards your organisation. It can significantly contribute to employee retention and overall organisational stability.

  • Support for Mental Well-Being

The major highlight of the group health insurance policy is that it can provide valuable support to relieve major stress levels. If you already know that your family is already covered under the group health insurance policy, then you may feel relaxed and free from mental stress. If an employer adds a teleconsultation feature into the policy, then it would ultimately help your family to access the support they need 24*7.

  • Cost-Effective

There is no arguing with the fact that these corporate group health insurance plans are incredibly cost-effective as compared to individual health plans. This affordability arises from the distribution of the insurer’s risk across a large pool of employees which results in a reduction of the cost of insurance on an individual basis. The best part is that it offers financial benefits for both employers and employees, which makes such a policy an attractive and cost-effective option for both parties.

  • Tax Benefits

Last but not least, group health insurance policies offer tax benefits to both employees and employers. The reason behind this is that both the parties are beneficiaries. This arrangement not only ensures comprehensive health coverage for employees but also offers financial advantages for employers through tax benefits.

What Are The Inclusions & Exclusions Under Group Health Insurance Policy?

Though there are many inclusions and exclusions under the Group Health Insurance Policy, we’ve listed down a few in both of them.

Inclusions:

  • In-Patient Hospitalisation Coverage

The first and foremost aspect that is included under the corporate health insurance policy is that it covers the expenses incurred when an insured individual is admitted to the hospital for treatment. To initiate a claim, the insured must undergo in-patient hospitalisation for a minimum duration of 24 hours.

  • Worldwide Hospitalisation Coverage

One of the key inclusions of the Group health insurance policy is that it extends beyond the borders of India. If an insured person requires hospitalisation outside the country, then the policy will cover the hospital bills, depending on the terms specified in the policy.

  • Daily Hospital Cash Benefit

Another major inclusion is that it includes medical procedures that do not necessitate a 24-hour hospital stay. Employees can file claims for such treatments under the health plan.

  • Road Ambulance Charges

It is one of the most important yet overlooked inclusions under the Group Health Insurance policy that the insured can claim expenses related to road ambulance services used for transportation to or from the hospital to their place of residence.

  • Loss of Pay Due to Hospitalisation

Lastly, another key inclusion under the policy is that it allows employees to claim a specified amount of money for a pre-determined number of months in the event of loss of pay resulting from hospitalisation.

Exclusions:

Listed below are the things not included under the Group Health Insurance Policy.

  • Gender Change Treatment

The first and foremost key exclusion under the corporate health insurance policy is that it doesn’t cover expenses related to treatment and surgery for gender change.

  • Cosmetic or Plastic Surgery

Another key exclusion is that it will not cover expenses for cosmetic or plastic surgery unless it’s for reconstruction following accidents, burns, cancer, or as part of medically necessary treatment.

  • Addiction Treatment

The Group health insurance policy will not cover expenses for treating alcoholism, drug, or substance abuse, or any addictive condition and their consequences.

  • Unproven Treatment

The corporate health insurance policy will not cover expenses associated with unproven treatments, services, and supplies.

  • Miscellaneous Treatment

Another key aspect that is not covered under the Group Health Insurance policy is that it will not cover expenses related to injuries from adventure sports, legal breaches, sterility, and infertility treatments.

Things to Consider When You Are Comparing Group Health Insurance

Here is a list of things that one must take into consideration while comparing Group Health Insurance.

  • Add-Ons

One of the key aspects that you must consider before opting for a corporate health insurance policy is choosing add-ons. When comparing group policies, ensure that any necessary add-ons for employees with chronic conditions are covered under the policy.

  • Convenience

However it is the most overlooked aspect when choosing a group health plan, it should be taken into priority. Ensure you choose a dedicated policy with smooth and hassle-free claims procedures to encourage employees to utilize their benefits effectively.

  • Value for Money

There is no arguing with the fact that cost plays an incredibly important factor in deciding the ideal Group health insurance plan. Before opting for the policy, consider the cost offered as even a slight increase in the policy premium will increase the policy benefit that will prove valuable to you in the long run.

  • PAN India Presence

Another major aspect to consider before choosing the corporate health policy is that one must evaluate the network of hospitals and clinics included in the insurance company’s network to ensure employees have access to quality healthcare services across the nation.

  • Consider Extra Benefits

Last but not least, ensure you choose a policy that offers additional wellness and preventive care benefits customised for your needs. Make sure you check how easy it is for employees to access and utilize these extra benefits, and select a plan that provides comprehensive coverage through user-friendly features and mobile applications.

How To Buy a Group Health Insurance Policy?

If you are looking to purchase a Group Health Insurance Policy, make sure you do it with the complete procedure. Firstly, it is important to evaluate the specific needs and requirements of the group for which the policy is intended. In the next step, it is advisable to research and compare different insurance providers and their reputations, range of coverage options, CSR (Claim Settlement ratio), claim process, and more.

Once a suitable insurance provider has been identified, it is essential to carefully review the terms and conditions of the policy and pay close attention to coverage, limits, deductibles, and things that are not covered under the policy. Then, it is recommended to thoroughly complete the online/offline application process and provide accurate information and any necessary documentation. In case you run into any troubles, feel free to connect with the customer care team of the concerned insurance provider.

When you follow these steps, you can navigate the process of buying a group Health Insurance Policy effectively and efficiently.

How To File a Claim for Your Group Health Insurance Policy?

When it comes to filing a claim for your Group Health Insurance policy, there are two ways in which you can do it.

  • Cashless Process
  • Reimbursement Process

Let’s first discuss the Claim Process;

Cashless Claim:

In the event of hospitalisation at one of the insurer’s network hospitals, you won’t be required to make any payment directly to the hospital for covered expenses. Instead, the insurer will settle the expenses directly with the hospital on your behalf. Here are the steps to follow the process in case of a cashless claim.

Step 1: In the first step, you will need to approach the Insurance/TPA help desk located within the insurer’s network hospital, along with the necessary documents (mentioned below).

Step 2: After that, the insurance desk will help in completing the pre-authorisation form and collect all the supporting medical records.

Step 3: Once the hospitalisation sends the pre-authorisation request to the insurer, then the insurer will review the payable/admissible amount and approve the cashless facility following the policy terms and conditions.

Step 4: In the fourth step, the claim will be settled as per the policy conditions and the payment will be made directly to the network hospital.

Step 5: In the last step of the cashless claim process, if there is any outstanding balance beyond the approved amount will need to be settled by you at the time of discharge from the hospital. Once settled, you can then be discharged from the hospital.

Reimbursement Process:

The following are the steps to consider while filing a claim following the reimbursement process.

Step 1: Collect Documentation

The first key step in the reimbursement claim process is that you must collect all paid bills with detailed breakdowns, duly signed and stamped by the hospital authority. Additionally, collect copies of treatment records such as indoor case papers, treatment charts, and vital charts.

Step 2: Submission Process

In the next step, you will need to submit or courier the specified documents to the insurer’s address to proceed with the reimbursement process.

Step 3: Timely Submission

After that, you will then need to submit the documents to the respective TPA (Third-Party Administrator) within 30 days of discharge or as indicated in the policy schedule.

Step 4: Processing & Settlement

If the submitted documents fulfil the requirements for claim processing, the settlement of the claimed amount will be credited to your account within 15 days of receiving the last document.

Note: In case of any deficiencies in the submitted documents, a notification will be sent to your registered email ID. You will be given a specified period to provide the necessary documents. If you fail to do so within the given time, then it will result in the claim being closed and marked as “No Claim”.

Documents Required for Making a Claim Under Group Health Insurance Policy

There are two sets of documents required for both the cashless claim and reimbursement claim process.

In the case of Cashless Claims:

  • Insurance card/policy copy
  • Address Proof
  • Copy of the Company Photo ID
  • Duly Filed CKYC form
  • Admission notes from the treating doctor
  • Previous OPD Consultation papers with reports if any.
  • Previous discharge summary or any other medical records available.

In case of Reimbursement Claims:

  • Insurance Card/ Policy Copy
  • Duly Filled & Signed Claim form,
  • Original discharge summary & Original consolidated final bill
  • Medical Certificate signed by the doctor
  • Supportive Investigation Reports
  • Invoice Break-ups required for the submitted final bill
  • In the case of implants, invoices are needed.
  • In case of Accidental injuries, MLC/ FIR is required
  • Cash-paid receipts of hospital/pharmacy/lab
  • In case of death of the main member, details of the nominee (as per policy schedule), along with address & ID proof of nominee.
  • Bank details of payee name with printed.
  • In case, the claim value is above Rs. 1 Lakhs, CKYC forms are required.

Frequently Asked Questions

No, COVID-19 is not a requirement for all Indian group health insurance plans. However, the majority of insurance companies have expanded COVID-19 coverage under their group health insurance plans.

As such, there is no upper or lower limit. The majority of insurance providers set a minimum limit of ten workers for group health insurance policies.

Yes, by the terms and circumstances of a Group Health Insurance policy, immunizations for a newborn insured are covered.

It is advised that employees get a health examination before enrolling in group health insurance, even if it is not usually required.

Maternity benefits are frequently included under corporate health insurance plans to help policyholders during their pregnancies and deliveries.

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